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In-Depth From A.D.A.M. Prevention

Patients who have had a first stroke or TIA are at high risk of having another stroke. Secondary prevention measures are essential to reduce this risk.

Lifestyle Changes

Quit Smoking. Smoking is a major risk factor for stroke. Patients should also avoid exposure to second-hand smoke.

Eat Healthy. Patients should make dietary changes to follow a diet rich in fruits and vegetables, high in potassium, and low in saturated fats. Limit sodium (salt) intake to less than 2,300 mg/day. Middle-aged and older patients with high blood pressure should restrict sodium intake to no more than 1,500 mg/day. For diet plans, the Mediterranean diet or the Dietary Approaches to Stop Hypertension (DASH) diet may be particularly good choices for reducing the risk of stroke.

Exercise. Exercise helps reduce the risk of atherosclerosis, which can help reduce the risk of stroke. Doctors recommend at least 30 minutes of exercise on most, if not all, days of the week.

Maintain Healthy Weight. Patients who are overweight should try to lose weight through healthy diet and regular exercise.

Limit Alcohol Consumption. Heavy alcohol use and binge drinking increase the risk of both ischemic and hemorrhagic stroke. If you drink, limit alcohol to no more than one drink a day for women or two drinks a day for men.

Antiplatelet and Anticoagulant Medications for Preventing Stroke

Your doctor may suggest taking aspirin or another drug called clopidogrel (Plavix) to help prevent blood clots from forming in your arteries or your heart. These medicines are called antiplatelet drugs. These drugs make blood platelets less sticky and therefore less likely to form a clot. You should never start taking aspirin without talking to your doctor first.

Primary Prevention (to prevent a first stroke). When these drugs are taken before a stroke or TIA has occurred, it is called primary prevention. Before deciding whether someone should take aspirin or clopidogrel to prevent strokes caused by a blockage in an artery (ischemic stroke), your doctor must consider whether you are at an increased risk of strokes caused by bleeding in the brain (hemorrhagic stroke), as well as bleeding elsewhere in the body.

For men and women of any age who are felt to be at low risk for having a stroke, there is no evidence that taking aspirin will help prevent one.

Women ages 55 - 79 years should take daily aspirin if they are at risk for stroke or heart attack. Some of these risk factors are high blood pressure, diabetes, smoking, a history of cardiovascular disease, atrial fibrillation, and left ventricular hypertrophy.

Women who are younger than age 55 should not take aspirin for primary prevention of stroke

Men ages 45 - 79 years should take aspirin if they are increased risk for heart attack. Aspirin is not recommended in men to prevent stroke, however. Some of the risk factors for coronary artery disease and heart attack are high blood pressure, diabetes, smoking, a history of cardiovascular disease, atrial fibrillation, and left ventricular hypertrophy.

Men younger than age 45 should not take aspirin for primary prevention.

For women and men age 80 years or older, it is not clear if the benefits of aspirin for stroke prevention outweigh the risks for bleeding in the digestive tract or brain.

Secondary Prevention (to prevent another stroke after one has occurred). After an ischemic stroke or a TIA, aspirin alone or aspirin plus the the anti-clotting drug dipyridamole (Persantine, or Aggrenox when combined in one pill with aspirin) given twice daily is recommended to prevent another stroke. Clopidogrel may be used in place of aspirin for patients who have narrowing of the coronary arteries or who have had a stent inserted. Combining aspirin and clopidogrel together does not have any more benefit and increases the risk for hemorrhage.

Anticoagulant Drugs. Warfarin (Coumadin) is the main anticoagulant (“blood thinner”) drug used to prevent strokes in high-risk patients with atrial fibrillation. Warfarin carries a risk for bleeding, but for most patients, warfarin’s benefits far outweigh its risks. The risk for bleeding is highest when warfarin therapy is first started, with higher doses, and with long periods of treatment. Patients at risk for bleeding are usually older and have a history of stomach bleeding and high blood pressure. It is important that patients who take warfarin have their blood checked regularly to make sure that it does not become “too thin.” Blood that is too thin increases the risk for bleeding, while blood that is “too thick” increases the risk for blood clots and stroke. Prothrombin time (PT) and international normalized ratio (INR) tests are used to monitor blood coagulation.

People with atrial fibrillation who are generally considered candidates for warfarin therapy often have one or more of the following characteristics:

History of blood clots to the lungs, stroke, or transient ischemic attack

Have a blood clot in one of their heart chambers

Significant valvular heart disease

High blood pressure

Diabetes, with age older than 65 years

Left atrium (one of the chambers of the heart) is enlarged

Coronary artery disease

Heart failure

Age 75 years or older

Control Diabetes

People with diabetes should aim for fasting blood glucose levels of less than 110 mg/dl and hemoglobin A1C of less than 7%. Blood pressure goals for people with diabetes should be 130/80 mm Hg or less.

Control Blood Pressure

Reducing blood pressure is essential in stroke prevention. Otherwise healthy patients with high blood pressure should aim for blood pressure below 140/90 mm Hg. Patients with diabetes, chronic kidney disease, or atherosclerosis should aim for blood pressure below 130/80 mm Hg. Drug therapy is recommended for people with hypertension who cannot control their blood pressure through diet and other lifestyle changes. Many different types of drugs are used to control blood pressure. They include diuretics, ACE inhibitors, angiotensin-receptor blockers, beta-blockers, and calcium channel blockers.

Hypertension is a disorder characterized by chronically high blood pressure. It must be monitored, treated, and controlled by medication, lifestyle changes, or a combination of both.

Lower LDL Cholesterol

The American Heart Association recommends that patients who have had an ischemic stroke or TIA should take a statin drug to lower cholesterol levels. Most patients should aim to lower their LDL (“bad” cholesterol) to less than 100 mg/dL. Patients with multiple risk factors should aim for an LDL level of below 70 mg/dL.

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